Langguth Berthold, De Ridder Dirk
Interdisciplinary Tinnitus Clinic, Department of Psychiatry and Psychotherapy, University of Regensburg, Regensburg, Germany.
Handb Clin Neurol. 2013;116:441-67. doi: 10.1016/B978-0-444-53497-2.00036-X.
Tinnitus is a common disorder and traditional treatment approaches such as medication, active or passive sound enhancement, and cognitive behavioral therapy have limited efficacy. Thus, there is an urgent need for more effective treatment approaches. Functional imaging studies in patients with tinnitus have revealed alterations in neuronal activity of central auditory pathways, probably resulting as a consequence of sensory deafferentation. However, nonauditory brain areas are also involved. These nonauditory brain areas might represent both an "awareness" network involved in the conscious perception of the tinnitus signal as well as areas related to a nontinnitus-specific distress network consisting of the anterior cingulate cortex, anterior insula, and amygdala. Moreover, memory mechanisms involving the hippocampus and the parahippocampal region may play a role in the persistence of the awareness of the phantom percept, as well as in the reinforcement of the associated distress. All of these networks represent potential targets for treatment via pharmacological treatment or noninvasive and invasive brain stimulation. Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive method of applying electromagnetic fields to the brain that can induce alterations of neuronal activity that outlast the stimulation period. Single sessions of rTMS over the temporal or temporoparietal cortex have been successful in transiently reducing tinnitus perception. Repeated sessions of rTMS have resulted in tinnitus relief in a subgroup of patients, lasting from several days to several months. However, effect sizes of rTMS in the treatment of tinnitus are only moderate, and interindividual variability is high. Larger and longer lasting effects have been observed with direct electrical stimulation of the auditory cortex via implanted epidural electrodes. Transcranial direct current stimulation (tDCS) has also shown potential for the treatment of tinnitus. Both auditory and frontal tDCS have shown tinnitus reduction in a subgroup of patients. In spite of the promising results of the different brain stimulation approaches, further research is needed before these techniques can be recommended for routine clinical use.
耳鸣是一种常见病症,药物治疗、主动或被动声音增强以及认知行为疗法等传统治疗方法疗效有限。因此,迫切需要更有效的治疗方法。对耳鸣患者的功能成像研究显示,中枢听觉通路的神经元活动发生了改变,这可能是感觉传入阻滞的结果。然而,非听觉脑区也参与其中。这些非听觉脑区可能既代表了参与耳鸣信号有意识感知的“意识”网络,也代表了与由前扣带回皮质、前岛叶和杏仁核组成的非耳鸣特异性痛苦网络相关的区域。此外,涉及海马体和海马旁区域的记忆机制可能在幻听感知的持续存在以及相关痛苦的强化中发挥作用。所有这些网络都是通过药物治疗或非侵入性及侵入性脑刺激进行治疗的潜在靶点。重复经颅磁刺激(rTMS)是一种将电磁场应用于大脑的非侵入性方法,可诱导神经元活动的改变,且这种改变在刺激期过后仍持续存在。在颞叶或颞顶叶皮质进行单次rTMS治疗已成功短暂减轻耳鸣感知。多次rTMS治疗使一部分患者的耳鸣得到缓解,持续时间从几天到几个月不等。然而,rTMS治疗耳鸣的效应大小仅为中等,个体间差异较大。通过植入硬膜外电极直接电刺激听觉皮质观察到了更大且更持久的效果。经颅直流电刺激(tDCS)也显示出治疗耳鸣的潜力。听觉和额叶tDCS均在一部分患者中显示出耳鸣减轻。尽管不同的脑刺激方法取得了有前景的结果,但在这些技术可被推荐用于常规临床使用之前,还需要进一步研究。
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